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In this section, we are interested in investigating the how states’ insurance coverage relates to two broad classes of outcomes - health outcomes and cost containment outcomes. We anticipate that an increase in health insurance coverage in a state would be correlated with increased health (though there is unlikely to be a significant causal relationship due to the short time span since the ACA went into effect). Moreover, an increase in health insurance coverage would likely shift some of the financial burden from individual out of pocket (OOP) costs to the premiums paid (pooled risk) and to the state.

We are interested in finding out which states perform well in which outcomes, as well as eventually develop an indicator of how states fare overall.

Health Outcomes and Access

Figure 8

We explore how health insurance rates correlates with health outcomes. In particular, we can look at the measure of mortality amenable to healthcare intervention - the number of deaths that could have been prevented by healthcare in the year 2014. We plot avoidable mortality (2014) against insurance rates (2014) and observe a negative relationship as expected. States that have higher rates of insurance also have better health in this respect. However, we also control for income levels as low income levels would be a major predictor of poor health, as confirmed in our plot. Yet, within each income level, the negative relationship remains, and it is especially pronounced among the upper-middle income countries.

Figure 9

The following maps how the states performed in the following health outcomes:

  1. Preventable mortality - deaths amenable to healthcare intervention, per 100,000 population (2014)

  2. Adults with access to a usual source of care (2015)

  3. Rate of age- and gender-appropriate cancer screenings in adults

  4. Rate of age-appropriate vaccinations in adults (2014)

A green color always incidates a comparatively more favorable outcome, while a red color indicates a less favorable outcome (2015)

We note that the Northeast (New England) states perform consistently well across all health outcomes, while the Southeast states, as well as Texes, peform consistently poorly on all except for vaccination rates. The Western and Rocky Mountains states have a low avoidable mortality rate, despite having low rates of access to usual care and of cancer screening and vaccinations. In the measure of adult vaccination rates, the trend of the South faring poorer on health is reversed, as they do comparatively well in vaccinations.

Affordability and Cost Outcomes

Figure 10

Figure 10 demonstrates a clear negative relationship between the insured rate and the percentage of people with high out-of-pocket (OOP) medical costs relative to their annaul household income. This suggests, as we expect, that as more people get insured, they are less likely to be paying excessive out-of-pocket costs for medical expenses. This relationship holds even after controlling for income level.

There was no conclusive relationship when the other two cost outcomes - annual growth in family premiums and increase in federal spending - were plotted against the insured rate.

Figure 11

Similarly, we map how the states performed in the following financial and cost outcomes:

  1. Percentage of people with high OOP costs relative to annual household income (2015)

  2. Average annual premium growth rate from 2010 to 2015

  3. Affordability of the marketplace plans, measured by the marketplace consumers who can obtain a plan less than $100 (2017). Note that states that do not operate a insurance marketplace are shaded in gray.

  4. Net increase in federal spending (in millions of dollars) over the period (up till 2016)

As before, a green color incidates a comparatively more favorable outcome, while a red color indicates a less favorable outcome.

We notice that states that do better in containing OOP costs tend to do worse in containing premium and marketplace plan rates as well as federal spending. These include some states like New York, New Jersey and Ohio in the Northeast and Midwest (Great Lakes). A notable exception is Massachussets, which performs well across the financial measures, possibly because of the headstart it got with “Romney-care”, which actually served as a model for Obamacare.

Summary of States’ Performance

Finally, we want to compare how the states do across both health and cost outcomes, and eventually get to some form of ranking of the states.

The following data table presents the rankings of the states on the following insurance coverage, health and affordability outcomes, providing a summary of the states’ performance:

  1. Percentage of population insured

  2. Deaths preventable by healthcare intervention (per 100,000 people)

  3. Proportion of adults with access to a usual source of care

  4. Proportion of people with high out-of-pocket costs (relative to household income)

  5. Annual rate of health insurance premium growth from 2010 to 2015

  6. Net increase in federal spending on healthcare up till 2016

A rank of 1 always indicates the more favorable outcome (i.e. higher insurance and treatment access rate, lower preventable mortality, OOP costs, premium growth, and federal spending increase).

Figure 12

Figure 13

We present a way of aggregating the rankings of the states in the above six health measures into an overall rank. We rank each state on each of three dimensions, insurance coverage, health outcomes, and cost control outcomes. For the health and cost control outcomes, since they have multiple subcomponents (2 and 3 respectively, as in the data table), we take an average over these subcomponent ranks. We then add up the ranks in the three dimensions to find an overall rank to order the states.

States at the top of this chart (with lower rank numbers) perform the best on the whole in their healthcare system. Mouse over the interactive plot to view the overall state rank. Note that you can toggle the three criteria on and off to include or exclude each criteria from the graph.

We see that many of the states with high-performing healthcare systems are New England states, including Vermont, Rhode Island, Massechussets and Connecticut, while Minnesota and Iowa also perform well. At the other end, the poorest performing states across all measures are Georgia, Oklahoma, Louisiana and Texas, mostly states in the Southeast and Southwest.